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Record Release Form

Record Release Form

As the person whose full name is mentioned hereinabove, I authorize RidgeView Optometry to release the following designated medical information.

Information to be Released

Copy of complete medical records including results of diagnostic testingCopy of contact lens prescriptionCopy of spectacle lens prescriptionInsurance information

Record Release Form

I have read and understood this form. I voluntarily authorize the disclosure of my health information as described in this form. If I am signing for a minor child, I attest I have legal authority to make medical designations for the designated minor.

Printed name if signed on behalf of the patient

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RidgeView Optometry

8540 Scarborough Dr, Ste 240
Colorado Springs, CO 80920

Call Us Today:
(719) 495-5904

MON 8:00am - 5:00pm
TUE-FRI 8:00am - 5:30pm
SAT-SUN Closed

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